Provider Demographics
NPI:1891062295
Name:JOHNSON, GRACITA (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:GRACITA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2110
Mailing Address - Country:US
Mailing Address - Phone:954-720-9243
Mailing Address - Fax:954-720-4567
Practice Address - Street 1:6401 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2110
Practice Address - Country:US
Practice Address - Phone:954-720-9243
Practice Address - Fax:954-720-4567
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist